Common use of Radiation Therapy/Chemotherapy Services Clause in Contracts

Radiation Therapy/Chemotherapy Services. Outpatient 10% - After deductible Not Covered In a physician’s office 10% - After deductible Not Covered Inpatient 10% - After deductible Not Covered Outpatient 10% - After deductible Not Covered Skilled or sub-acute care 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 Not Covered When rendered by our designated telemedicine provider. $40 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 100% - After deductible Not Covered In a physician’s office 100% - After deductible Not Covered Inpatient 100% - After deductible Not Covered Outpatient 100% - After deductible Not Covered Skilled or sub-acute care 100% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 100% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 Not Covered When rendered by our designated telemedicine provider. $40 0% - After deductible Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 10% - After deductible Not Covered In a physician’s office 10% - After deductible Not Covered Inpatient 10% - After deductible Not Covered Outpatient 10% - After deductible Not Covered Skilled or sub-acute care 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 20 - After deductible Not Covered When rendered by our designated telemedicine provider. $40 25 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 10% - After deductible Not Covered In a physician’s office 10% - After deductible Not Covered Inpatient 10% - After deductible Not Covered Outpatient 10% - After deductible Not Covered Skilled or sub-acute care 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 Not Covered When rendered by our designated telemedicine provider. $40 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 1020% - After deductible Not Covered In a physician’s office 1020% - After deductible Not Covered Inpatient 1020% - After deductible Not Covered Outpatient 1020% - After deductible Not Covered Skilled or sub-acute care 1020% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 1020% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 1020% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 1020% - After deductible Not Covered In a physician’s office $30 20% - After deductible Not Covered When rendered by our designated telemedicine provider. $40 20% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 10% - After deductible Not Covered In a physician’s office 10% - After deductible Not Covered Inpatient 10% - After deductible Not Covered Outpatient 10% - After deductible Not Covered Skilled or sub-acute care 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 20 Not Covered When rendered by our designated telemedicine provider. $40 35 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 10% - After deductible Not Covered In a physician’s office 10% - After deductible Not Covered Inpatient 10% - After deductible Not Covered Outpatient 10% - After deductible Not Covered Skilled or sub-acute care 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 Not Covered When rendered by our designated telemedicine provider. $40 30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 100% - After deductible Not Covered In a physician’s office 100% - After deductible Not Covered Inpatient 100% - After deductible Not Covered Outpatient 100% - After deductible Not Covered Skilled or sub-acute care 10% $300 per admission - After deductible Afterdeductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% $40 - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 100% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 100% - After deductible Not Covered In a physician’s office $30 0% - After deductible Not Covered When rendered by our designated telemedicine provider. $40 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 10% - After deductible Not Covered In a physician’s office 10% - After deductible Not Covered Inpatient 10% - After deductible Not Covered Outpatient 10% - After deductible Not Covered Skilled or sub-acute care 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $20 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 Not Covered When rendered by our designated telemedicine provider. $40 35 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 10% - After deductible Not Covered In a physician’s office 10% - After deductible Not Covered Inpatient 10% - After deductible Not Covered Outpatient 10% - After deductible Not Covered Skilled or sub-acute care 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Skilled or sub-acute care 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 20 Not Covered When rendered by our designated telemedicine provider. $40 35 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 10% - After deductible Not Covered In a physician’s office 10% - After deductible Not Covered Inpatient 10% - After deductible Not Covered Outpatient 10% - After deductible Not Covered Skilled or sub-acute care 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 Not Covered When rendered by our designated telemedicine provider. $40 30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 100% - After deductible Not Covered 20% - After deductible In a physician’s office 100% - After deductible Not Covered Inpatient 1020% - After deductible Not Covered Outpatient 10Inpatient 0% - After deductible Not Covered 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled or sub-acute care 100% - After deductible Not Covered 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 1020% - After deductible Not Covered 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 100% - After deductible Not Covered 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 100% - After deductible Not Covered 20% - After deductible In a physician’s office $30 Not Covered 15 20% - After deductible When rendered by our designated telemedicine provider. $40 30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not CoveredSee the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 100% - After deductible Not Covered 20% - After deductible In a physician’s office 100% - After deductible Not Covered Inpatient 1020% - After deductible Not Covered Outpatient 10Inpatient 0% - After deductible Not Covered 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled or sub-acute care 100% - After deductible Not Covered 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 100% - After deductible Not Covered 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 100% - After deductible Not Covered 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 100% - After deductible Not Covered 20% - After deductible In a physician’s office $30 Not Covered 20 20% - After deductible When rendered by our designated telemedicine provider. $40 50 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not CoveredSee the covered healthcare service being provided for the amount you pay